Many people taking long-term corticosteroids worry about adrenal crisis. Some are frightened of going to sleep in case they do not wake up. Others feel unexpectedly unwell when reducing their steroid dose, while some discover that nobody has explained what to do with their medication when they become ill.
These concerns deserve to be taken seriously. However, adrenal suppression, adrenal insufficiency and adrenal crisis are not the same thing. Understanding the differences, recognising problems during steroid reduction and having a clear plan for illness can make living with the condition safer and less frightening.
This is particularly relevant to people with allergic bronchopulmonary aspergillosis (ABPA), severe asthma and other respiratory conditions who may need repeated or prolonged corticosteroid treatment. Certain antifungal medicines can also increase the effects of some corticosteroids, adding to the risk of adrenal suppression.
What is steroid-induced adrenal insufficiency?
Your adrenal glands normally produce cortisol, a hormone that helps regulate blood pressure, blood glucose, metabolism and the body’s response to illness or physical stress.
Cortisol production is controlled by signals from the brain, particularly the hypothalamus and pituitary gland. Together with the adrenal glands, these form the hypothalamic-pituitary-adrenal (HPA) axis.
When you take corticosteroid medicines, such as prednisolone, methylprednisolone or hydrocortisone, the body senses that sufficient glucocorticoid is available and may reduce its own cortisol production.
With prolonged exposure, the adrenal glands may become less able to produce cortisol when it is needed. This is called glucocorticoid-induced adrenal insufficiency, sometimes described as secondary or tertiary adrenal insufficiency.
The risk depends on the dose, duration, formulation, route of administration, other medicines and individual susceptibility. Oral steroids are an important cause, but inhaled, injected, nasal and topical corticosteroids can also contribute, particularly with prolonged use, high exposure or interacting medicines.
For a more detailed explanation, read Understanding Steroids, Cortisol, ACTH and Adrenal Suppression in Aspergillosis.
Adrenal suppression is not the same as adrenal crisis
This distinction is important because the terms are sometimes used interchangeably, creating unnecessary anxiety.
- Adrenal suppression means the body’s normal cortisol-producing system has been reduced by corticosteroid exposure. The degree of suppression varies.
- Adrenal insufficiency means the body cannot produce enough cortisol for its needs, particularly when steroid treatment has been reduced or stopped, or during illness.
- Adrenal crisis is an acute, potentially life-threatening shortage of glucocorticoid activity that can cause severe illness and circulatory collapse. It requires immediate emergency treatment.
Not everyone with adrenal suppression develops clinically significant adrenal insufficiency, and not everyone with adrenal insufficiency experiences an adrenal crisis.
For people receiving appropriate treatment and following a suitable illness-management plan, adrenal crisis is not an inevitable outcome. Nevertheless, the risk must be recognised because delayed treatment can be dangerous.
Could I have an adrenal crisis while asleep?
Some patients describe a particular fear of going to sleep and not waking up. This may arise after learning that adrenal crisis can be fatal.
Having adrenal insufficiency does not mean that someone is likely to die in their sleep. An unexpected overnight crisis is not the usual course in a person who is well, receiving appropriate glucocorticoid replacement and following their prescribed treatment plan.
However, serious illness, infection, repeated vomiting, missed essential medication or an inability to absorb oral steroids can create a dangerous shortage of cortisol activity. Deterioration can sometimes occur rapidly.
Rather than living in constant fear, the most useful protection is to understand your individual risk, take prescribed medication reliably, recognise warning signs and have clear emergency instructions.
If anxiety about adrenal crisis is disrupting your sleep or daily life, discuss it with your endocrine or prescribing team. A clear written plan may help address uncertainty.
Why do I feel so unwell when reducing steroids?
This is one of the most common and confusing experiences reported by people reducing long-term corticosteroid treatment.
Symptoms may include profound tiredness, weakness, muscle or joint aches, nausea, low mood, dizziness and a general feeling of being unwell.
There are three important possible explanations, and more than one may occur at the same time.
1. Glucocorticoid withdrawal syndrome
After prolonged steroid treatment, the body may need time to adapt to lower glucocorticoid exposure.
People can experience fatigue, muscle aches, joint pain, sleep disturbance and low mood even while receiving steroid doses that are sufficient to prevent adrenal crisis.
This is known as glucocorticoid withdrawal syndrome. It does not necessarily mean that the adrenal glands have failed or that an adrenal crisis is developing.
2. Adrenal insufficiency
As the steroid dose approaches the amount normally produced by the body, inadequate recovery of the HPA axis may become clinically important.
The body may not yet be able to produce enough cortisol independently. Symptoms can resemble withdrawal syndrome, making the two difficult to distinguish without clinical assessment.
Recovery can take weeks, months or sometimes considerably longer. The timing varies between individuals.
3. Return of the underlying respiratory disease
Corticosteroids suppress inflammation. Reducing them may allow symptoms of ABPA, asthma or another inflammatory condition to return.
Increasing breathlessness, wheezing, coughing or mucus production may therefore reflect worsening respiratory disease rather than adrenal insufficiency.
This is particularly difficult in aspergillosis because fatigue and weakness can accompany both respiratory illness and steroid-related problems.
The important message: Feeling unwell during steroid reduction does not automatically mean you are developing an adrenal crisis. However, significant or persistent symptoms should be discussed with your clinical team, and severe deterioration requires urgent assessment.
How should steroids be reduced safely?
There is no single tapering schedule suitable for everyone.
The rate of reduction depends on the underlying condition, the steroid dose and duration, the risk of adrenal suppression and how the patient responds.
When steroids are still needed to control active ABPA or asthma, the priority is to manage that disease safely. Once the underlying condition is adequately controlled, the dose may be reduced towards physiological replacement levels under clinical supervision.
At lower doses, the possibility of adrenal insufficiency becomes particularly relevant. Some patients need slower reductions, clinical reassessment or tests of adrenal recovery.
The 2024 European Society of Endocrinology and Endocrine Society guideline advises that routine adrenal testing is generally unnecessary while patients remain on supraphysiological glucocorticoid doses or still require glucocorticoids for their underlying disease. When assessing recovery at physiological doses, morning serum cortisol is usually the initial test.
Never stop long-term corticosteroid treatment suddenly or change a tapering schedule without appropriate medical advice.
What happens when I become ill?
Normally, the body produces more cortisol during significant physical stress, such as a serious infection, injury or surgery.
People with adrenal insufficiency may be unable to increase cortisol production sufficiently. They may therefore need additional glucocorticoid treatment during illness, commonly called sick-day rules or stress dosing.
This is a crucial aspect of adrenal safety, yet some patients report that they have never been given clear instructions.
Anyone with confirmed adrenal insufficiency, or who is considered at clinically significant risk of adrenal suppression, should know whether they need illness-related steroid adjustments and what those adjustments are.
Instructions depend on the person’s diagnosis, current steroid treatment, degree of risk and clinical circumstances. Patients should receive an individualised plan from their prescribing or endocrine team.
Illness that may require additional steroids
Examples include a significant infection with fever, an illness causing marked physical stress, serious injury or surgery.
Mild everyday symptoms do not necessarily require additional steroid treatment. The distinction should be explained in your personal sick-day plan.
Do not improvise additional doses without knowing the instructions that apply to you.
Vomiting or diarrhoea
Vomiting is particularly important because oral steroid medication may not be absorbed or retained.
People who depend on glucocorticoid replacement must have clear instructions about what to do if they vomit after taking medication, have repeated vomiting or develop severe diarrhoea.
If you cannot keep essential steroid medication down, follow your emergency plan and seek urgent medical care. An emergency glucocorticoid injection may be required.
People prescribed an emergency injection kit should be trained in its use, and family members or carers may also benefit from training.
Does every kind of stress mean I need extra steroids?
People with adrenal insufficiency are often told that they need additional steroids during stress. This can be confusing because the word “stress” describes many different experiences, from infection and surgery to anxiety, exercise and hot weather.
Not every stressful situation requires additional steroid medication. The important question is whether the situation creates a significant additional demand for cortisol that your body may be unable to meet.
Physical illness and injury
Fever, significant infections, major injuries and surgery are well-recognised situations in which people with adrenal insufficiency may need additional glucocorticoids.
Follow your individual sick-day plan. Severe illness, repeated vomiting or inability to retain essential medication may require emergency injected steroids and urgent medical care.
Hot weather and dehydration
Ordinary hot weather does not automatically mean you need to increase your steroid dose.
However, excessive heat can cause dehydration, dizziness, low blood pressure and heat-related illness. These problems may be particularly important for someone with adrenal insufficiency.
During hot weather, drink sufficient fluids, avoid prolonged overheating and take precautions against dehydration. If you become seriously unwell, collapse or cannot retain medication, seek urgent medical help and follow your emergency steroid plan.
Anxiety and emotional stress
Ordinary worry, anxiety or everyday emotional stress does not usually require additional steroid medication.
Severe psychological stress, such as an exceptionally distressing event, may sometimes justify temporary adjustments under an individualised endocrine plan. Guidance is less precise in this area than for fever, surgery or major physical illness.
Anxiety can also cause physical symptoms such as palpitations, nausea, sweating and dizziness. These can overlap with symptoms associated with adrenal insufficiency, making the situation particularly worrying.
Do not routinely increase steroid doses in response to anxiety unless this is part of your agreed treatment plan. If symptoms are severe, persistent or accompanied by signs of acute illness, seek medical assessment rather than assuming they are caused by anxiety.
Exercise and physical exertion
Normal daily activities and moderate exercise do not usually require additional steroids in people receiving appropriate replacement treatment.
Unusually strenuous or prolonged exertion may require individual advice, particularly in people who have previously experienced difficulties during exercise.
Discuss demanding activities, endurance events or physically stressful travel with your endocrine team if you have confirmed adrenal insufficiency.
The practical message: Ask your clinical team to explain which kinds of stress require additional steroids in your circumstances. A written sick-day plan should distinguish everyday activities from significant illness and emergencies.
How do I recognise a possible adrenal crisis?
Adrenal crisis is a medical emergency. Symptoms can develop during an acute illness or following inadequate glucocorticoid exposure.
Warning features may include:
- Severe weakness or sudden marked deterioration.
- Collapse, fainting or very low blood pressure.
- Confusion, unusual drowsiness or reduced consciousness.
- Persistent vomiting or severe diarrhoea, especially when oral steroids cannot be retained.
- Severe abdominal pain or other symptoms of serious acute illness.
These symptoms are not unique to adrenal crisis. Severe infection, dehydration and other emergencies may cause similar problems. Patients should not attempt to distinguish these conditions at home when seriously unwell.
If adrenal crisis is suspected, call 999 immediately. Tell the emergency team that the person has adrenal insufficiency or may have steroid-induced adrenal suppression.
If an emergency glucocorticoid injection has been prescribed, administer it according to the patient’s emergency instructions. Do not delay emergency treatment while waiting for blood tests or confirmation of the diagnosis.
In hospital, suspected adrenal crisis requires prompt parenteral glucocorticoid treatment and appropriate intravenous fluids. Emergency treatment should not be delayed for diagnostic testing.
Should I carry a steroid emergency card?
People with adrenal insufficiency, and some people at risk because of current or recent corticosteroid treatment, should carry an appropriate steroid emergency card.
In the UK, the NHS Steroid Emergency Card helps healthcare professionals recognise patients who may require urgent steroid treatment during illness or medical emergencies.
A card does not mean that a crisis is expected. It is a practical safety measure, particularly if the patient is unable to explain their medical history.
Ask your GP, pharmacist or specialist team whether you need a card, and ensure your medical records clearly document any confirmed adrenal insufficiency or significant risk.
Further information is available from NHS England: Steroid Emergency Card patient safety guidance.
Why are antifungal medicines important?
This issue is particularly relevant to people with aspergillosis.
Azole antifungal medicines, including itraconazole, voriconazole and posaconazole, can inhibit enzymes involved in the breakdown of certain corticosteroids.
As a result, some corticosteroids may remain in the body longer or produce greater systemic effects than expected.
Interactions involving inhaled corticosteroids, particularly fluticasone and some other preparations, can lead to excessive glucocorticoid exposure, Cushingoid features and suppression of the body’s own cortisol production.
Adrenal insufficiency may then become apparent when the interacting antifungal or corticosteroid is reduced or stopped.
Importantly, the interaction can change when either medicine is started or discontinued. Treatment changes may therefore require coordinated review by the respiratory, pharmacy and endocrine teams.
Never assume that inhaled corticosteroids cannot cause adrenal suppression. If you take an azole antifungal alongside any corticosteroid, ask your specialist pharmacist or prescriber to check the combination.
Read more about antifungal drug interactions.
Can my adrenal glands recover?
Yes. Many people recover normal cortisol production after reducing or stopping glucocorticoid treatment, although recovery can be slow.
Some recover within weeks or months, while others require replacement treatment for much longer. Occasionally, suppression persists for years.
Recovery depends on several factors and cannot reliably be predicted from symptoms alone.
Your clinical team may use morning cortisol measurements and, when appropriate, additional endocrine investigations to assess recovery.
Until recovery has been demonstrated or your specialist advises otherwise, continue following the steroid safety instructions provided to you.
What should I ask my doctor?
If you have taken long-term steroids, are reducing treatment or have been diagnosed with adrenal insufficiency, these questions may help:
- Do I have confirmed adrenal insufficiency, or am I considered at risk of developing it?
- Am I currently taking enough glucocorticoid to cover my normal daily requirements?
- Do I need a steroid emergency card?
- What exactly should I do with my steroid medication if I develop a fever or significant infection?
- What should I do if I vomit or cannot keep my medication down?
- Do I need an emergency injection kit, and who will teach me to use it?
- Could my antifungal medication be increasing the effects of my corticosteroids?
- How will we assess whether my adrenal function has recovered?
- Who should I contact if I feel unwell during steroid tapering?
Ask for your illness-management instructions in writing. This is especially helpful when different teams are involved in your care.
Living with adrenal insufficiency without living in fear
It is understandable to be frightened after learning that adrenal crisis can be life-threatening. Some people become particularly anxious about sleeping, infections, travelling or being alone.
But having adrenal insufficiency does not mean that an emergency is constantly about to happen.
Most day-to-day management involves taking prescribed medication correctly, understanding when additional treatment may be needed, keeping appropriate emergency information available and seeking help promptly when seriously unwell.
Equally, patients should not be expected to work out illness dosing or emergency treatment for themselves. Clear instructions and access to professional advice are essential parts of safe care.
The aim is not to make patients constantly alert for disaster. It is to help them recognise when action is genuinely needed and feel confident that they know what to do.
Key points
- Adrenal suppression is not the same as adrenal crisis. Having suppressed cortisol production does not mean a crisis is inevitable.
- Feeling unwell during steroid tapering has several possible causes. Withdrawal symptoms, adrenal insufficiency and worsening respiratory disease may overlap.
- Illness dosing is an essential safety issue. People with confirmed adrenal insufficiency or significant risk should have clear, individualised instructions.
- Vomiting and inability to retain essential steroids require particular attention. Follow your emergency plan and seek urgent help.
- Suspected adrenal crisis is an emergency. Call 999 and follow prescribed emergency injection instructions.
- Antifungal interactions matter. Azole medicines can increase exposure to certain corticosteroids and contribute to adrenal suppression.
- Adrenal function can recover. Recovery varies and should be assessed with appropriate clinical guidance.
Further reading and authoritative guidance
- European Society of Endocrinology and Endocrine Society: Diagnosis and Therapy of Glucocorticoid-Induced Adrenal Insufficiency (2024).
- NHS England: Steroid Emergency Card Patient Safety Alert.
- NHS: Addison’s Disease and Adrenal Crisis — includes general information about adrenal insufficiency and emergencies, although steroid-induced adrenal insufficiency has a different cause.
- Understanding Steroids, Cortisol, ACTH and Adrenal Suppression in Aspergillosis.
- Antifungal Drug Interactions: What Patients Need to Know.
This article provides general patient information. Steroid tapering, replacement treatment, sick-day dosing and emergency injection plans must be individualised by an appropriately qualified healthcare professional. The article does not replace personal medical advice or emergency care.
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